{"subscriber":false,"subscribedOffers":{}} Lessons From An Immigrant-Focused Community COVID-19 Vaccination Organization | Health Affairs

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Lessons From An Immigrant-Focused Community COVID-19 Vaccination Organization

A syringe sits above three vials of COVID-19 vaccine.

Three snapshots from Minneapolis, Minnesota’s Seward neighborhood:

April 2021: The week before Ramadan, the Somali mosque is crowded with dozens of people who’ve come for their COVID-19 vaccine. Over three chaotic days, 239 people will be vaccinated; 16 are older than age 65 and have already been eligible for nearly three months.

August 2021: This time the mosque is vaccinating older children in a community where children’s vaccinations have been intensely controversial. The event vaccinates 27 children and teenagers and 17 adults over two crowded hours; all but two return in three weeks for their second Pfizer dose. Across town, events organized for similar communities by larger hospital systems struggle to find takers.

January 2022: This time the clinic is at the neighborhood’s other mosque, which serves congregants of the Oromo ethnicity. At a time when it is easy to assume that those remaining unvaccinated are unreachable, 65 people come for shots, 20 of them primary-series vaccinations.

These snapshots—reflecting some of nine successful vaccination events held between April 2021 and February 2022—are the product of a distinctive community vaccination model organized by the Seward Vaccine Equity Project, a small, all-volunteer organization formed in the aftermath of the George Floyd uprising. The Seward neighborhood of Minneapolis is almost evenly split between a White population and a population of East African refugee and immigrant families; our organization exists specifically to make COVID-19 vaccines accessible to the neighborhood’s East African population. Our active membership, which has never numbered more than 10 at any given time, is Somali, Oromo, White, and African American.

We are not the only ones to focus on the East African residents of this neighborhood: Beginning in 2010, Andrew Wakefield and other anti-vaccine activists targeted this community for anti-vaccine outreach, including multiple personal visits and public events designed to instill fear of MMR vaccines. It worked; the result was a measles outbreak—in 2011, and another in 2017—in this community. The belief that vaccines cause autism, especially in children, remains widespread.

Amid these challenges, our model has proven effective. Over our first year, we organized more than 500 full primary-series vaccinations and booster shots. Our work offers five lessons about organizing vaccine access, both in times of scarcity and in times of abundant supply but hesitant uptake:

1. Organizing, Not Health Provision

Our model relies on intensive word-of-mouth outreach and is based on principles used in community and union organizing: Using the communication methods most common in community members’ daily lives, personally confirming attendance at events, listening rather than making assumptions, and having widely respected community membersconversations in their own communities drive the work. We recruit people for vaccination in one-on-one conversations at the neighborhood’s Somali and Oromo mosques, the local Section 8 housing towers (not always with the blessing of building management), neighborhood soccer teams, and immigrant-owned small businesses. We offer transportation to vaccination clinics to anyone who needs it.

In deference to the largely oral Somali and Oromo cultures, our intake system is designed to prioritize conversation. Signing up is easy: During conversations, Somali and Oromo speakers in our organization fill out very minimal “vaccine interest forms” on paper, collecting only name, phone number, and birthday. At our April 2021 clinics, about 50 people listed a birthday of January 1—the pattern of a population that has not always needed to keep clear records of births. Other volunteers type that information into spreadsheets, so our Somali- and Oromo-speaking volunteers use their time on conversations, not paperwork.

Our group uses “turnout” techniques from union and community organizing, which emphasize frequent contact with community members, with the goal that they will repeatedly confirm their commitment to attend an event. Everyone who signs up receives a follow-up phone call, which acts as both a reminder and space to respond to new concerns or challenges, and a subsequent reminder text message in their language of choice. Outreach volunteers are also frequently physically present in mosques, Section 8 housing, and other key locations to have further conversations or answer questions.

In contrast to traditional health promotion approaches based on communications from outside experts, our community organizing model draws on the unique talents and connections of our members. Somali outreach is led by a Somali American pharmacy owner with deep connections to the community and is aided by an experienced Somali American civil rights organizer; Oromo outreach is led by an Oromo American epidemiology graduate student whose family are longtime members of the Oromo mosque. Beyond these core group members, additional outreach work has been done by mosque leaders, the local youth soccer coach, and a union organizer living in the Section 8 housing towers. These organizers and others we rely on for outreach all live in, work in, or otherwise have deep ties to the neighborhood. In addition, several of our other core members had prior experience with community, political, or union organizing, and one had professional connections that facilitated health systems being willing to take a chance on us before we had established a track record of successful events.

2. Facilitating Collaboration Between Health Bureaucracies And Trusted Organizations

Our group began by helping neighbors, particularly African immigrants, to secure vaccinations one by one. Through identifying scarce appointments and arranging transportation, we helped dozens of high-risk people get vaccinated in early 2021. By late March, we wanted to do something on a larger scale. Ramadan was coming up, and we knew that many high-risk people in our neighborhood might not want to get a vaccine, with its potential side effects, during a month when they would be fasting. If we wanted our neighborhood to be protected, people needed to be vaccinated before the holiday began. As the state opened up vaccine eligibility to all adults, we organized three vaccination events in a four-day span.

At the time, vaccine supply was vastly outstripped by demand, and health systems charged with shepherding the scarce supply had the remit of, above all, not wasting doses. Organizations needed to collect information and guarantee a certain number of appointments to move forward with any planned event; but many of the organizations with the greatest community trust were too small, too informal, or too busy to do the work that health systems required. In this clash of needs, the Seward Vaccine Equity Project was able to play an essential bridging role. In addition to our intensive outreach to individuals, we connected with small membership organizations—the Black Immigrant Collective and a labor union representing janitors and security officers—and did the bureaucratic work to sign up anyone they identified who wanted a vaccine. The unique combination of our own members’ networks let us serve as the go-between for organizations with high levels of community trust and health systems charged with distributing vaccines.

Our vaccination events’ success also rested on health systems taking a certain leap of faith. To maximize the number of doses offered daily, vaccinations were still by appointment only when we organized our first large events in April 2021. However, the people we were vaccinating were largely from cultures that do not typically rely on appointment slots for daily activities. As such, for our events before Ramadan, regardless of appointment time, the mosque told people to arrive for their shots an hour before the clinic began (which meant that when many arrived hours “late,” they were still within clinic hours). Our volunteers developed intake systems that could register people on the spot as walk-ups arrived. We used every dose, all of it going to the populations we had intended—but often not going to the specific individuals who were signed up, as many of them did not show up but equally many others took their place in what had become a word-of-mouth-driven community event.

3. Money Is A Mixed Blessing

Our group started without funding, and our core members are all volunteers. In summer 2021, our member leading Somali-language outreach found that the most common first question she was asked was, “Who’s paying you to do this?” It mattered that she could honestly say, “Nobody; I just think this is the right thing to do.”

During that same time period, we gained access to state and county funding for the first time, which we used for financial incentives and to belatedly compensate some long-term partners—such as the mosque where most events occurred, the soccer coach who did a great deal of outreach work, and a neighborhood restorative justice nonprofit that acted as our fiscal sponsors so that we, as an informal group, could receive money in the first place.

Payment has helped keep us from wearing out our welcome with community partners after repeated requests for assistance. But money also changed the relationship with one key partner from being one of mutual collaboration to being more transactional, in a way that ultimately limited our ability to collaborate.

Another challenge of using financial incentives (whether $50 provided by us or state incentive programs offering $100 or $200, with our volunteers filing participants’ paperwork) was the question raised by skeptics during outreach: “Why does the state want me to do this so badly that they’ll pay for it?” The answer we settled on was designed to validate their skepticism while making it seem compatible with accepting vaccination for one’s own reasons: “The state wants to save money, and it thinks $100 is cheaper than what it’ll pay if you end up in the hospital.”

But the upside of incentives was also very real, as we saw in a particularly dramatic way at our January 2022 clinic at the Oromo mosque. Following prayers, parents came to our table asking, “Why is my son badgering me to let him get vaccinated now?” The $50 incentive seemed tremendously appealing to teenage boys in particular, who—possibly reflecting the culture of some families in which teenagers often help immigrant parents navigate bureaucracies—in some cases convinced their entire family to get their first shots all together. That clinic was particularly successful, giving 65 vaccinations when we had anticipated giving about a dozen.

4. Fatalism Is Always Easy, And Often Wrong

When vaccine supply was small relative to demand in early 2021, it was already apparent that racial disparities in vaccination were becoming entrenched. A common equity response to these disparities was to impose rules limiting vaccine access to those who seemingly needed it the most. For example, Minnesota prioritized clinics in certain high-risk ZIP codes. Around the country, these equity efforts failed to meet their targets as clinics intended to reach people of color and people in economically deprived neighborhoods were flooded by more advantaged vaccine-seekers from other areas. And so, in the early vaccine rollout, we found that a particular kind of cynicism was widespread even among those deeply committed to health equity: the sense that equity efforts would inevitably be subject to elite capture.

Our equity approach illustrates a different model, largely based on relaxing rules rather than imposing them. Although we are a neighborhood organization, we made vaccines available without regard to where people lived. This proved very important because many of the people who worship at the Somali mosque drive in from outlying suburbs where housing is less expensive than in the city. Our relaxed approach to equity rules was eventually accepted by health systems who, to their great credit, saw that we were more successful in reaching high-risk populations than the far more common ZIP code-based clinics were and allowed us the flexibility to vaccinate people we identified through our outreach networks, rather than rigorously proving those people’s heightened need.

There was one key precondition for our approach to work: We never allowed any of our events to be advertised anywhere online. This let us relax eligibility rules without being flooded by low-risk people seeking an early vaccine; we could focus on simply making vaccines available to the higher-risk people we identified directly. For this word-of-mouth-driven campaign, social segregation worked to our advantage: Even amid intense “vaccine hunter” social media efforts, our vaccine slots weren’t claimed by people outside our prioritized communities because those people never realized our events existed.

Our efforts worked: In the first four months of vaccine eligibility beyond Phase 1a in Minnesota, we secured vaccines for about 300 people, virtually all of whom were people of color from one or another high-risk community (such as immigrants and residents of dense low-income housing or large multigenerational households).

Once vaccines became widely available, fatalism wore a different face. These days, a common cynical take is that, by now, everyone who wants to be vaccinated has had their chance. Even we worry before each event that nobody will show up. At times, the result is perhaps comical: At our January 2022 clinic, we repeatedly ran out of incentive money and resorted to emptying our own checking accounts and a nearby friend’s supply of emergency cash, as dozens of unexpected people showed up to be vaccinated. Yet, beneath the farcical chaos is a real lesson: Even in 2022, there are still plenty of people to be reached.

5. Cross-Cultural Efforts Lead To Better Outcomes

Our group’s successes have hinged on our diversity, as each of our unique networks and skills have played a role. Yet, our neighborhood’s intense segregation—with adjacent blocks being, respectively, overwhelmingly White or overwhelmingly African—means that we could easily have never met one another. That we did meet reflects the unique context of Minneapolis during the pandemic. After George Floyd was killed by police officer Derek Chauvin and Chauvin’s precinct building, located just three blocks south of our neighborhood, was burned to the ground in retaliation, a racially and politically diverse group of neighbors began discussing an expanded vision of neighborhood public safety. The informal network that became our group’s core membership formed through those conversations.

Our success may also reflect more permanent aspects of our neighborhood: It is highly walkable and filled with small businesses, including two independent pharmacies that both participated in our efforts (one Somali-owned, one Oromo-owned). The Somali pharmacy owner who has led most of our outreach has been particularly invaluable. She is widely known and trusted in the neighborhood—where her pharmacy is often the site of wide-ranging conversations among community members who stop by and take a seat—and has the competence to answer questions about the vaccine. One block west of her pharmacy is a local bookstore with a chatty atmosphere, where a chance encounter late in 2021 produced a crucial connection that facilitated our providing booster shots to custodians at the nearby university, many of them Oromo immigrants. In many neighborhoods, such settings simply do not exist.

Our experience suggests one final lesson: Effective mobilization for population health may depend on neighborhood residents forming real ties that cross-cut networks, so that the strengths of each can work in concert toward specific health goals. A long-term approach to recreating pandemic readiness might also mean combatting social segregation and atomization.

Authors’ Note

Inari Mohammed works as an epidemiologist with the Minnesota Department of Health. Elizabeth Wrigley-Field’s research on COVID-19 mortality is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development via the Minnesota Population Center (P2C HD041023). All authors are among the core membership of the Seward Vaccine Equity Project.

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